Bipolar disorder - Treating bipolar disorder

Treatment for bipolar disorder aims to reduce the number and severity of the episodes of depression and mania that characterise the condition. In doing so, a person can live as normal a life as possible.

Treatment options for bipolar disorder

If a person is not treated, episodes of bipolar-related mania can last for between three and six months. Episodes of depression tend to last longer, for between 6 and 12 months.

However, with effective treatment, episodes usually improve within about three months.

Most people with bipolar disorder can be treated using a combination of different treatments. These can include one or more of the following:

medication to prevent episodes of mania, hypomania (less severe mania) and depression – these are known as mood stabilisers and are taken every day on a long-term basis
medication to treat the main symptoms of depression and mania when they occur
learning to recognise the triggers and signs of an episode of depression or mania
psychological treatment – such as talking therapies, which help you deal with depression and provide advice on how to improve relationships
lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, and advice on improving your diet and getting more sleep

Read more about living with bipolar disorder.

Most people with bipolar disorder can receive most of their treatment without having to stay in hospital.

However, hospital treatment may be needed if your symptoms are severe, or if you are being treated under the Mental Health Act, as there is a danger you may self-harm or hurt others.

In some circumstances, you could have treatment in a day hospital and return home at night.

Medication

Several medications are available to help stabilise mood swings. These are commonly referred to as mood stabilisers and include:

lithium carbonate
anticonvulsant medicines
antipsychotic medicines

If you are already taking medication for bipolar disorder and you develop depression, your GP will check you are taking the correct dose. If you aren't, they will change it.

Episodes of depression are treated slightly differently in bipolar disorder, as the use of antidepressants alone may lead to a hypomanic relapse.

Most guidelines suggest depression in bipolar disorder can be treated with just a mood stabiliser. However, antidepressants are commonly used alongside a mood stabiliser or antipsychotic.

Lithium carbonate

In the UK, lithium carbonate (often referred to as just lithium) is the medication most commonly used to treat bipolar disorder.

Lithium is a long-term method of treatment for episodes of mania, hypomania and depression. It is usually prescribed for at least six months.

If you are prescribed lithium, stick to the prescribed dose and do not stop taking it suddenly (unless told to by your doctor).

For lithium to be effective, the dosage must be correct. If it is incorrect, you may get side effects such as diarrhoea and vomiting. However, tell your doctor immediately if you have side effects while taking lithium.

You will need to have regular blood tests at least every three months while taking lithium. This is to make sure your lithium levels are not too high or too low.

Your kidney and thyroid function will also need to be checked every two to three months if the dose of lithium is being adjusted, and every 12 months in all other cases.

While you are taking lithium, avoid using non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, unless they are prescribed by your GP.

In the UK, lithium and the antipsychotic medicine aripiprazole are currently the only medications licensed for use in adolescents with bipolar disorder who are aged 13 or over.

However, the Royal College of Paediatrics and Child Health states that unlicensed medicines may be prescribed for children if there are no suitable alternatives and their use can be justified by expert agreement.

Anticonvulsant medicines

Anticonvulsant medicines include:

These medicines are sometimes used to treat episodes of mania. They are also long-term mood stabilisers.

Anticonvulsant medicines are often used to treat epilepsy, but they are also effective in treating bipolar disorder.

A single anticonvulsant medicine may be used, or they may be used in combination with lithium when the condition does not respond to lithium on its own.

Valproate

Valproate is not usually prescribed for women of childbearing age because there is a risk of physical defects to babies such as spina bifida, heart abnormalities and cleft lip. There may also be an increased risk of developmental problems such as lower intellectual abilities, poor speaking and understanding, memory problems, autistic spectrum disorders and delayed walking and talking.

In women, your GP may decide to use valporate if there is no alternative or if you've been assessed and it's unlikely you'll respond to other treatments, although they will need to check you're using a reliable contraception and advise you on the risks of taking the medicine during pregnancy.

If you are prescribed valproate, you will need to visit your GP to have a blood count when you begin the medication, and then again six months later.

Carbamazepine

Carbamazepine is usually only prescribed on the advice of an expert in bipolar disorder. To begin with, the dose will be low and then gradually increased.

Your progress will be carefully monitored if you're taking other medication, including the contraceptive pill.

Blood tests to check your liver and kidney function will be carried out when you start taking carbamazepine, and again after six months.

You will also need to have a blood count at the start and after six months, and you may also have your weight and height monitored.

Lamotrigine

If you are prescribed lamotrigine, you will usually be started on a low dose, which will be increased gradually.

See your GP immediately if you are taking lamotrigine and develop a rash. You will need to have an annual health check, but other tests are not usually needed.

Women who are taking the contraceptive pill should talk to their GP about taking a different method of contraception.

Antipsychotic medicines

Antipsychotic medicines are sometimes prescribed to treat episodes of mania or hypomania. Antipsychotic medicines include:

They may also be used as a long-term mood stabiliser. Quetiapine may also be used for long-term bipolar depression.

Antipsychotic medicines can be particularly useful if symptoms are severe or behaviour is disturbed. As antipsychotics can cause side effects – such as blurred vision, dry mouth, constipation and weight gain – the initial dose will usually be low.

If you are prescribed an antipsychotic medicine, you will need to have regular health checks at least every three months, but possibly more often, particularly if you have diabetes. If your symptoms don't improve, you may be offered lithium and valproate as well.

Aripiprazole is also recommended by the National Institute for Health and Care Excellence (NICE) as an option for treating moderate to severe manic episodes in adolescents with bipolar disorder.

Rapid cycling

You may be prescribed a combination of lithium and valproate if you experience rapid cycling (where you quickly change from highs to lows without a "normal" period in between).

If this doesn't help, you may be offered lithium on its own or a combination of lithium, valproate and lamotrigine.

However, you will not usually be prescribed an antidepressant unless an expert in bipolar disorder has recommended it.

Learning to recognise triggers

If you have bipolar disorder, you can learn to recognise the warning signs of an approaching episode of mania or depression.

This will not prevent the episode occurring, but it will allow you to get help in time.

This may mean making some changes to your treatment, perhaps by adding an antidepressant or antipsychotic medicine to the mood-stabilising medication you are already taking. Your GP or specialist can advise you on this.

Psychological treatment

Some people find psychological treatment helpful when used alongside medication in between episodes of mania or depression. This may include:

psychoeducation – to find out more about bipolar disorder
cognitive behavioural therapy (CBT) – this is most useful when treating depression
family therapy – a type of psychotherapy that focuses on family relationships (such as marriage) and encourages everyone within the family or relationship to work together to improve mental health

Psychological treatment usually consists of around 16 sessions. Each session lasts an hour and takes place over a period of six to nine months.

Pregnancy

The management of bipolar disorder in women who are pregnant, or those who are trying to conceive, is complex and challenging.

One of the main problems is the risks of taking medication during pregnancy are not always that well understood.

The National Institute for Health and Care Excellence (NICE) recommends that the risks of treating or not treating women with bipolar disorder during pregnancy should be fully discussed.

NICE also recommends that specialist mental health services work closely with maternity services.

A written plan for managing the treatment of a pregnant woman with bipolar disorder should be developed as soon as possible.

The plan should be drawn up with the patient, her partner, her obstetrician (pregnancy specialist), midwife, GP and health visitor.

The following medication is not routinely prescribed for pregnant women with bipolar disorder:

valproate – there is a risk to the foetus and the subsequent development of the child
carbamazepine – it has limited effectiveness and there is risk of harm to the foetus
lithium – there is a risk of harm to the foetus, such as cardiac problems
lamotrigine – there is a risk of harm to the foetus
paroxetine – there is a risk of harm to the foetus, such as cardiovascular malformations
benzodiazepines – if used long term, there are risks during the pregnancy and immediately after the birth, such as cleft palate and floppy baby syndrome

If you become pregnant while taking medication prescribed to treat bipolar disorder, it's important that you do not stop taking it until you have discussed it with your doctor.

If medication is prescribed for bipolar disorder after the baby is born, it may also affect a mother's decision to breastfeed her child. Your pharmacist, midwife or mental health team can give you advice based on your circumstances.